MEDICARE: LAKESIDE MEDICAL ASSOCIATES, A MEDICAL GROUP, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number State
1	363L00000X	Nurse Practitioner	CA
2	207R00000X	Internal Medicine Physician	CA
3	208000000X	Pediatrics Physician	CA
4	207Q00000X	Family Medicine Physician	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1619975158
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKESIDE MEDICAL ASSOCIATES, A MEDICAL GROUP, INC.

Provider Business Mailing Address
First Line	:	777 FLOWER ST
Second Line	:	SUITE A
City	:	GLENDALE
State	:	CA
Zip	:	91201-3015
Country	:	US
Telephone Number	:	818-637-2000
Fax Number	:	818-242-8761

Provider Business Practice Location Address
First Line	:	12660 RIVERSIDE DR
Second Line	:	SUITE 310/320
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91607-3429
Country	:	US
Telephone Number	:	818-755-0391
Fax Number	:	818-753-8165

Authorized Official
Title or Position	:	PRESIDENT
Name	:	KERRY E. WEINER
Credential	:	M.D.
Telephone Number	:	818-637-2000

Provider Enumeration Date	:	07/08/2005
Last Update Date	:	05/06/2009

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Directions to “LAKESIDE MEDICAL ASSOCIATES, A MEDICAL GROUP, INC. ” Practice Location

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